Recessive dystrophic epidermolysis bullosa (RDEB): Oral manifestation and management rules in oral surgery: A case report

INTRODUCTION AND IMPORTANCE

The recessive dystrophic epidermolysis bullosa is a severe form of hereditary epidermolysis bullosa characterized by deformities of the skin, blisters and erosions on the mucous membranes. Oral manifestations are frequent and extensive vary from small discrete vesicles to large bullae, associated with microstomia, ankyloglossia and a depapilled tongue. The purpose of this case report is to describe oral health status of patient with recessive-dystrophic epidermolysis bullosa, and the measures that dentists should adopt with the purpose of provide an effective dental treatment.

CASE PRESENTATION

We present a clinical case of a patient with recessive-dystrophic epidermolysis bullosa who underwent a bone regularization and whose follow-up was carried out until healing.

CLINICAL DISCUSSION

The management of patients with RDEB in oral surgery requires the adoption of an atraumatic technique and certain precautions to limit the formation of bullae and promote mucosal healing.

CONCLUSION

We can conclude that oral management of patients with recessive dystrophic epidermolysis bullosa presents a challenge for the oral surgeon and the management is generally multidisciplinary and relies essentially on the adoption of a preventive and atraumatic approach.

[Hereditary epidermolysis bullosa: French national guidelines (PNDS) for diagnosis and treatment]

Hereditary epidermolysis bullosa (EB) is a heterogeneous group of rare genetic diseases characterized by fragile skin and/or mucous membrane, and it may be either local or generalized. It is caused by mutations in genes encoding different proteins involved mainly in the structure and function of the dermal-epidermal junction. Nineteen genes have so far been identified. They are classified by level of skin cleavage (from top to bottom) into four groups: EB simplex, junctional EB, dystrophic EB and Kindler syndrome. Clinically suspected diagnosis is confirmed by immunohistochemical examination of a skin biopsy at specialized centres in order to determine the level of cleavage and the deficient protein. This first step may be followed by genetic analysis. The severity of the disease is highly variable, ranging from localized forms with little effect on quality of life to rapidly lethal forms. In generalized severe forms, the extent and chronicity of lesions, as well as mucosal involvement, can lead to systemic complications: malnutrition, pain, joint contractures, chronic inflammation, amyloidosis, cutaneous squamous cell carcinoma. Some specific forms are associated with other cutaneous signs (nail involvement, alopecia, hyperpigmentation, palmoplantar keratoderma) or extracutaneous involvement (muscular dystrophy or pyloric atresia). No curative treatment of EB is available today. EB requires multidisciplinary medical care, nursing, psychological and social management. This is best provided by a specialized network, involving reference centres, centres of expertise and daily caregivers. The goal of treatment is the prevention and treatment of lesions with specific non-adherent dressings and the prevention, detection and treatment of complications. It is essential not to traumatize the skin (bandaging, friction, etc.). Protein, gene or cell replacement therapy, and allogeneic bone marrow, cord blood or pluripotent stem-cell transplantation are currently being assessed. The aim of these French recommendations (national diagnostic and treatment protocol [PNDS]) is to provide healthcare professionals with guidance on the course of EB and on optimal patient management.

[Recessive epidermolysis bullosa due to composite heterozygote mutations in the COL7A1 gene]

BACKGROUND

Dystrophic epidermolysis bullosa (DEB) is a genodermatosis characterized by various abnormalities of anchoring fibrils, composed mainly of type VII collagen, at the dermal-epidermal junction. These changes are induced by mutations in the type VII collagen gene (COL7A1).

PATIENTS AND METHODS

A new-born boy was diagnosed with recessive DEB on the basis of typical skin lesions composed of multiple blisters with erosions on trauma-exposed body sites, including the hands and feet and the navel. Diagnosis was confirmed by pathology examination and irregular immunofluorescence staining of type VII collagen. Genomic DNA from the patient and parents were subjected to direct sequencing for the COL7A1 gene. Two heterozygous mutations were detected in the affected child. Each parent was a carrier of one heterozygous mutation.

DISCUSSION

Over 730 mutations of the COL7A1 gene have been identified as responsible for phenotypic polymorphism of EBD. The relatively mild phenotype seen in our patient, known as "non-Hallopeau-Siemens" or "mitis" EBD, is due to residual synthesis of collagen VII. The mutation present on the maternal allele that prevents synthesis of collagen VII is compensated by the mutation on the paternal allele, which enables more or less functional collagen VII synthesis.